| NPI | 1376696971 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NM PA2005-0019) |
| Additional Taxonomies | 363A00000X Physician Assistant (Licence: WI 1889) |
| Enumeration Date | 2007-01-19 |
| Last Update Date | 2023-11-15 |